KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment

Knowledge Application Program

KAP Keys
For Clinicians
Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov

KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment

Introduction
KAP Keys were developed to accompany the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA). These KAP Keys are based entirely on TIP 47 and are designed to meet the needs of the busy clinician for concise, easily accessible how to information. For more information on the topics in these KAP Keys, readers are referred to TIP 47.

Other Treatment Improvement Protocols (TIPs) that are relevant to these KAP Keys:
TIP 25: Substance Abuse Treatment and Domestic Violence (1997) BKD239 TIP 31: Screening and Assessing Adolescents for Substance Use Disorders (1999) BKD306 TIP 32: Treatment of Adolescents With Substance Use Disorders (1999) BKD307 TIP 39: Substance Abuse Treatment and Family Therapy (2004) BKD504 TIP 41: Substance Abuse Treatment: Group Therapy (2004) BKD507 TIP 45: Detoxification and Substance Abuse Treatment (2006) BKD541 TIP 46: Substance Abuse: Administrative Issues in Outpatient Treatment (2006) BKD545

Typical Sequence of Topics Addressed in Psychoeducational Groups KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment
Treatment Engagement Understanding motivation and committing to treatment Counteracting ambivalence and denial

Determining the seriousness of the drug or alcohol problem Conducting self-assessment, setting goals, and selfmonitoring progress Overcoming common barriers to treatment Early Recovery Learning about biopsychosocial disease and recovery processes Understanding the effects of specific drugs and alcohol on the brain and body Placing symptoms of substance use disorders in the context of other behavioral health problems Learning about early and protracted withdrawal symptoms for specific drugs and alcohol Knowing the stages of recovery and the clients place in the continuum of care Learning strategies for quitting and finding the motivation to stop Minimizing risks of HIV/AIDS, hepatitis C, and sexually transmitted diseases (STDs) Identifying high-risk situations that are cues or triggers to substance use: people, places, and things Identifying peer pressures and compulsive sexual behavior as triggers Understanding cravings and urges, learning to extinguish thoughts about substance use, and coping with cravings Structuring personal time Coping with high-risk situations Understanding abstinence and the use of prescription and over-the-counter medications Understanding the goals and practices of various 12-Step or other mutual-help groups Identifying and using positive support networks

Continued on back

Typical Sequence of Topics Addressed in Psychoeducational Groups KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment
Maintenance and Continuing Care Understanding the relapse process and common warning signs Identifying tools to prevent relapse Developing personal relapse plans Counteracting euphoria and the desire to test control Improving coping and stress management skills Learning anger management and relaxation techniques Enhancing self-efficacy for handling risky situations Responding safely to slips and avoiding escalation Finding recovery resources Structuring leisure time and finding recreational activities Knowing the importance of personal health: diet, exercise, hygiene, and checkups Taking a personal inventory Handling shame, guilt, depression, and anxiety Understanding family dynamics: enabling and sabotaging behaviors Rebuilding personal relationships Understanding sexual dysfunction and healthy sexual behavior Developing educational and vocational skills Learning daily living skills: money management, housing, and legal assistance Embracing spirituality and recovery and finding meaning in life Recognizing grief and loss and the relationship to substance use Learning about parenting: basic needs of children and their developmental stages and developmental tasks Maintaining balance in life See TIP 47, pages 3234.

Case Management Services KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment
Functions Provide a core set of social services that includes assessment, planning, linkage, monitoring, and advocacy. Provide the client with a single contact person who is responsible for finding and mobilizing needed resources, negotiating formal systems, and bartering informally with other service providers to gain access to appropriate services. Respond to clients needs, tailoring resources to the individual rather than fitting the client into existing services.

Intervene with many systems and providers on behalf of the client. Operate in the community and transcend facility boundaries. Focus on pragmatic, immediate ways to meet needs (e.g., clothing, shelter). React sensitively and competently to clients ethnic, gender, and cultural differences. Models Single agency model. Case managers personally establish relationships with counterparts in other agencies to find and access services for individual clients. Informal partnership model. Staff members from several agencies link into collaborative teams or networks that consult about individual cases and share services. Formal consortium model. Case managers and service providers are joined through written agreements or contracts that define roles, responsibilities, shared services, and costs. This model usually is organized by a lead agency that has primary responsibility and receives most or all of the funding. See TIP 47, pages 3840.

A Protocol for Ambulatory Detoxification and Disulfiram Induction KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment
First day: When BAL = 0: First night:

Chlordiazepoxide 50 mg hourly until anxiety is relieved50 mg to 300 mg Disulfiram 125 mg* Chlordiazepoxide 50 mg at bedtime; repeat hourly x 2 until asleep (3 doses provided) No medication Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if not asleep (2 doses provided) Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if not asleep (2 doses provided)

Second day: Second night:

Third night:

*Disulfiram is dispensed only at the clinic.

All

unused chlordiazepoxide doses must be returned to the clinic the following morning.

Source: G. Kolodner, M.D., personal communication, 2003.

See TIP 47, pages 5657.

Effective Interviewing Techniques KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment
Begin with a brief overview of the topics to be covered, the expected duration of the interview, and confidentiality requirements. Ask the least threatening questions first.

Listen attentively and reflectively. Restate what the individual said to determine the level of understanding. Provide enough time for the individual to express himself or herself. Support self-efficacy by communicating that the individual can change, make autonomous decisions, and act in his or her best interests. Affirm the strengths, and compliment the positive values of the client. Explain everything that is happening or planned in treatment, and allow time for questions. Ask open-ended questions that cannot be answered with a one-word response to encourage the individual to talk, describe feelings, and express opinions. Convey empathy through voice tone, facial expression, and body language as well as with direct expressions of caring. Observe the client for nonverbal expressions of feelings that may either be inconsistent with or confirm what the individual is saying. Avoid argument, remain nonjudgmental, and adjust to any resistance. Probe gently to clear up discrepancies and inconsistencies. Be completely candid and honest. Help the client move beyond anger, resentment, frustration, or defensiveness; even if the individual does not return, this single contact can be a constructive, positive influence. See TIP 47, pages 6163.

ABC Model for Psychiatric Screening KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment
Appearance, Alertness, Affect, and Anxiety Appearance: How are general hygiene and dress?

Alertness: What is the level of consciousness? Confusion? Affect: Are there signs of elation, anger, or depression in gestures, facial expression, and speech? Anxiety: Is the person nervous, phobic, or panicky? Behavior Movements: Is the person hyperactive, hypoactive/subdued, abrupt, agitated, or calm? Organization: Is the person coherent and goal oriented? Purpose: Is behavior bizarre, dangerous, impulsive, belligerent, or uncooperative? Speech: What are the rate, coherence, organization, content, and sound level? Cognition Orientation: To person, place, time, and condition Calculation: Memory and capability to perform simple tasks Reasoning: Insight, judgment, and problemsolving abilities Coherence: Delusions, hallucinations, and incoherent thoughts
Source: Center for Substance Abuse Treatment. (1994). Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse. Treatment Improvement Protocol (TIP) Series 9 (DHHS Publication No. SMA 94-2078.) Rockville, MD: Substance Abuse and Mental Health Services Administration.

See TIP 47, pages 6566.

Mild Withdrawal Symptoms for Four Drug Classes That Can Be Managed in Partial Hospitalization or Day Treatment Detoxification (Level II.5)

KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment
Alcohol Mild withdrawal without need for treatment with sedative-hypnotics; no hyperdynamic state; Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) score of 8; no significant history of morning drinking.

Sedative-hypnotics Mild withdrawal with history of almost daily sedative-hypnotic use; no hyperdynamic state; no need for treatment with sedative-hypnotics; no complicating exacerbation of affective disturbance; no dependence on other substances. Opioids Mild withdrawal in context of almost daily opioid use but no need for substitute agonist therapy; withdrawal symptoms respond well to symptomatic treatment; comfortable by the end of the days monitoring. Mild withdrawal involving lethargy, agitation, or depression; the client has sufficient impulse control, coping skills, or support to engage in treatment and to prevent immediate continued use.

Stimulants

Source: Mee-Lee, D., Shulman, G. D., Callahan, J. F., Fishman, M., Gastfriend D., Hartman, R., & Hunsicker, R. J. (Eds.). (2001). Patient Placement Criteria for the Treatment of Substance-Related Disorders: Second Edition-Revised (PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine.

See TIP 47, pages 7072.

A Treatment Calendar for Family Members KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment
Beginning Stage: 15 Weeks Commit to treatment.

Understand that a substance use disorder is a chronic illness. Support abstinence. Begin to identify and discontinue behaviors that support substance use. Learn about the family support groups: Al-Anon (www.al-anon.alateen.org) Nar-Anon (www.naranon.com) Families Anonymous (www.familiesanonymous.org). Middle Stage: 620 Weeks Assess the relationship with the client. Develop a realistic perspective on addiction-related behaviors so the family member remains involved with the client but establishes some protective personal distance. Work to eliminate behaviors that encourage the clients substance use (i.e., enabling behaviors). Move past behaviors that are primarily a response to the clients substance use (i.e., codependence). Seek new ways to enrich the family members life. Begin practicing new communication methods. Advanced Stage: 21+ Weeks Work to develop a healthy, balanced lifestyle that supports the client and addresses personal needs. Exercise patience with recovery. Evaluate and accept changes, adaptations, and limitations.
Source: Matrix Center. (1989). The Matrix Model of Outpatient Chemical Dependency Treatment: Family Education Guidelines and Handouts. Los Angeles: The Matrix Center.

See TIP 47, pages 98106.

A Relapse Prevention Quiz KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment

This quiz can be a tool to support and strengthen a clients readiness to avoid relapse. Having senior members in a group answer the questions reinforces their knowledge while they educate newer members in relapse prevention skills. What might you say to co-workers if they ask you to have a drink or get high with them? Craving a drink or drug is quite natural for people who are dependent on alcohol or drugs. What three things can you do to get past the craving? What are three common reasons for feeling that you dont belong in a support group such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)? What two things can you do if someone at an AA or NA meeting annoys you? Why must recovery from your disease be your highest priority? What three qualities should you look for in a sponsor? Emotional discomfort takes a variety of forms. What are the three biggest problems for you? Anger, depression, self-pity, loneliness, boredom, worry, frustration, shame, guilt, or another emotion? What three things can you do to handle each emotional discomfort you identified? What are the key elements of an assertive response when offered alcohol or drugs? Why is it important to avoid starting romantic relationships during early recovery? See TIP 47, pages 117119.

Urine Toxicology Detection Periods for Different Substances KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment

Substance Barbiturates Short-actingSecobarbital Long-actingPentobarbital Phenobarbital Benzodiazepines Therapeutic dose Chronic dosing Cocaine Cannabinoids Casual use Daily use Chronic use Ethanol (alcohol) Opioids (e.g., codeine, morphine) Methadone Propoxyphene Ecstasy/euphorics PCP Acute use Chronic use

Typical Urine Detection Period

Amphetamines or methamphetamines 24 days 12 days 24 days 1020 days 37 days Up to 30 days 13 days 13 days 510 days Up to 30 days 1224 hours 13 days 24 days 648 hours 15 days 27 days Up to 30 days

Copyright 1999 by the American Psychological Association. Adapted with permission. No further reproduction or distribution is permitted without the written permission of the American Psychological Association. (Preston, K. L., Silverman, K., & Cone, E. J. [1999]. Monitoring cocaine use during contingency management interventions. In S. T. Higgins & K. Silverman [Eds.], Motivating Behavior Change Among Illicit Drug Abusers [pp. 283308]. Washington, DC: American Psychological Association.)

See TIP 47, pages 237245.

Effectiveness of Drug Detection Methods 10 That Use Different Biological Products KAP Keys Based on TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment
Body Product Urine
Detection

Drug

Time

Major Advantages
Mature technique; established cutoffs for detecting many drugs of abuse Easy to use; readily available and wellestablished method Easy to obtain samples; good correlation with blood levels for some substances Cumulative measure; relatively tamper-proof collection method Accurate results; established method

Major Limitations
Detects only recent use; needs costly confirmation to be accurate Short detection time

Primary Use
Monitors recent drug use in many populations

24 days

Breath

(alcohol)

1224 hours

Confirms observed intoxication or impairment Links positive drug test to behavioral impairment and intoxication Detects recent and less recent drug use

Saliva

1224 hours

Very short detection time; new method; oral cavity is contaminated easily High potential for contamination; new technique

Sweat

14 weeks

Blood

1224 hours

Invasive method; expensive; detects only current use or intoxication New technique; costly and timeconsuming; no doseresponse relation established

Detects drug effects on crashes, medical emergencies Confirms drug use in past 4 to 6 months; prevalence studies

Hair

46 months

Measures long-term drug use; readily available samples; accurate results

Copyright 1999 by the American Psychological Association. Adapted with permission. No further reproduction or distribution is permitted without the written permission of the American Psychological Association. (Preston, K. L., Silverman, K., & Cone, E. J. [1999]. Monitoring cocaine use during contingency management interventions. In S. T. Higgins & K. Silverman [Eds.], Motivating Behavior Change Among Illicit Drug Abusers [p. 299]. Washington, DC: American Psychological Association.)

See TIP 47, pages 237245.

Ordering Information TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment

Three Ways to Obtain Free Copies of All TIP Products

1. Call SAMHSAs National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889. 2. Visit NCADIs Web site at www.ncadi.samhsa.gov. 3. Access TIPs online at www.kap.samhsa.gov.

Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

DHHS Publication No. (SMA) 07-4251 Printed 2007